Grievances & Appeals Representative

Humana; Arkansas; Remote; USD 43,000 - 57,000; Full time

Job summary

A health-focused insurance company is seeking a Grievances & Appeals Representative 3 in Arkansas. The role involves managing client denials, supporting members and providers through communication, and applying analytical skills. Ideal candidates should have customer service experience and strong technical skills. A competitive salary and benefits package are offered, along with opportunities for remote work.

Benefits

Medical, dental, and vision insurance

401(k) with company match

Paid time off

Disability and life insurance

Qualifications

• Minimum of two years of customer service experience.
• Prior experience in the healthcare field.
• Strong focus on customer service.

Responsibilities

• Assist members and providers via phone or written communication channels.
• Apply intermediate mathematical skills as needed.
• Prioritize requests and adapt procedures under limited guidance.

Skills

Customer service experience

Proficiency with Microsoft Office

Analytical skills

Data entry capabilities

Technical skills

Education

Associate or bachelor's Degree

Job description

Overview

Become a part of our caring community and help us put health first. The Grievances & Appeals Representative 3 manages client denials and concerns by conducting a comprehensive analytic review of clinical documentation to determine if an appeal, grievance, or further request is warranted, and then delivers a final determination based on trained skillsets and/or partnerships with clinical and other Humana parties. The Grievances & Appeals Representative 3 performs advanced administrative/operational/customer support duties that require independent initiative and judgment. May apply intermediate mathematical skills. The representative assists members and providers via phone or written communication channels to investigate and resolve inquiries. Decisions typically focus on methods, tactics, and processes for completing administrative tasks/projects. Regularly exercises discretion and judgment in prioritizing requests and interpreting and adapting procedures, processes and techniques while working under limited guidance due to previous experience and depth of knowledge.

Training and Schedule

Training: Monday-Friday, 8am-4:30pm Eastern, for 5 weeks, tentatively starting December 1st, 2025.

Schedule: Tuesday-Saturday, 10:30am-7pm Eastern. Must be able to work possible overtime, weekends and holidays based on business needs.

Responsibilities

• Assist members and providers via phone or written communication channels to investigate and resolve inquiries related to grievances and appeals.
• Apply intermediate mathematical skills as needed in job duties.
• Prioritize requests and adapt procedures, processes and techniques while working with limited guidance.

Required Qualifications

• Minimum of two years of customer service experience
• Prior experience working in the healthcare field and/or medical industry
• Excellent data entry capabilities
• Proficiency with Microsoft Office, including intermediate skills in Outlook, Excel, and PowerPoint
• Ability to adhere to process maps
• Experience working in a fast-paced, production-oriented environment
• Proven ability to prioritize tasks and manage inventory and workflow
• Strong focus on customer service, with keen analytical and decision-making abilities
• Robust technical skills, including the capability to set up and connect a computer with additional monitors, navigate multiple software systems and applications simultaneously, and effectively work from home
• Availability of a distraction-free workspace at home

Preferred Qualifications

• Associate or bachelor's Degree
• Previous inbound call center or related customer service experience
• Prior grievance and appeals experience
• Previous experience processing medical authorizations
• Prior experience with Medicare
• Experience with Clinical Guidance Exchange (CGX 2.0)
• Knowledge of medical terminology
• Ability to manage large volume of documents including tracking, copying, faxing and scanning
• Excellent interpersonal skills with ability to sensitively and compassionately interact with geriatric population

Additional Information

Work at Home Guidance

• To ensure home or hybrid home/office associates’ ability to work effectively, the self-provided internet service must meet criteria: minimum download speed of 25 Mbps and upload speed of 10 Mbps is recommended; wireless, wired cable or DSL connection is suggested.
• Satellite, cellular and microwave connection can be used only if approved by leadership.
• Associates who live and work from home in California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense.
• Humana will provide home or hybrid home/office associates with telephone equipment appropriate to meet business requirements.
• Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.

Interview Process

As part of our hiring process, HireVue may be used to enhance hiring decisions. It may include a Virtual Job Experience (VJE), a Video Prescreen, and interviews. Some applicants may be invited to schedule interviews, and offers follow finalists from the interview process.

Notes

Note: Depending on openings, applicants, and schedules, the process may take several weeks or less. Travel to Humana offices may be required occasionally for training or meetings.

Other Details

Scheduled Weekly Hours: 40

Pay Range: $43,000 - $56,200 per year. Base pay may vary by location and experience.

Benefits and About Us

Description Of Benefits: Competitive benefits including medical, dental, vision, 401(k), paid time off, holidays, volunteer time off, paid parental and caregiver leave, disability insurance, life insurance, and more.

About Us: Humana Inc. is committed to putting health first. Through Humana insurance services and CenterWell healthcare services, we support millions of people to achieve their best health.

Equal Opportunity Employer

Humana does not discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability, or protected veteran status. We provide affirmative action in compliance with applicable laws.